The award-winning blog of the Faculty of Public Health

Archive for November, 2018

One Saturday afternoon 2 years ago, not long after I had joined the Public Health training scheme, a WhatsApp message came through from one of my childhood friends. The remarkable thing about this was that my childhood friends are all from Yemen, and therefore all in the middle of ‘the War’, and so did not often have WiFi. The message meant that someone had managed to get hold of some increasingly unaffordable diesel, to power up a WiFi mast.

I rang her; she said there was no point video-calling as they had no electricity and all 8 of them were huddled around one solar-powered desk lamp in the basement, which also charged their phone. I felt a little unsure of what to say, so I switched my video on and walked them around my roomy house and we laughed at how many electrical appliances I had and how useless I would be should I also find myself in the middle of ‘the War’. I think they were just relieved to hear someone else’s voice, to have a sense that there was a part of the world where things were calm enough for things like toasters to exist, but after I had rung off my mind was buzzing and I felt a strange ache. What could I do? I felt far away and helpless.

But it made me think that is these very things that compelled me to pursue public health in the first place. I want to use whatever drop of energy I have in things that challenge my mind, but also give me heart ache; that bizarre human feeling of being both strong and weak all at once.

I felt it again today, while I sat on a train going to work reading a new report by Martha Mundy for the World Peace Federation; “Strategies of the Coalition in the Yemen War”. It is a fine piece of public health work. It collates and displays a range of data and information to generate patterns, from which to draw evidence-based conclusions, which are to motivate change that would save many many lives.

In general the war in Yemen, despite being in its fourth year, gets little press. However, as the civilian death toll in Yemen rises, there has been increasing international scrutiny of the Coalition, which consists of Saudi, backed by its allies the UK, France and the US. Are so many non-military hits justifiable?

It seems not.

This new report profiles large amounts of data on Coalition attacks in Yemen between March 2015 to March 2018. It describes the geography and changes in tactics of attacks over time, along with mapping out the proportion of attacks on civilians in the different governorate regions, shown in Figure 1 below.

Proportion of civilian, military and unknown targets in governorates of Yemen. YDP data March 2015 – March 2018.

“From August 2015 there appears a shift from military and governmental to civilian and economic targets, including water and transport infrastructure, food production and distribution, roads and transport, schools, cultural monuments, clinics and hospitals, houses, fields and flocks.”

In particular, the report maps the targeting of agricultural land and fisheries, and explains the consequences for a country on the brink of famine, that relies on small scale farming and fishing for survival.

The report describes some of the recent attacks with high civilian death counts, such as a school bus target from August this year, and then states:

These atrocities receive attention from the UN Humanitarian Affairs Coordinator and the international press, but shielded by allies, the Coalition remains exempt from any independent investigation to determine legal responsibility and from significant international mobilization to stop the war in Yemen.

Figure 2. All Agricultural targets

The conclusion that the report comes to is a clear one, as colluding in war crimes is not an allegation to make lightly:

If the Coalition war in Yemen is not to mark the erasure of legal referent in war, other forces and institutions will need to call into question the blanket ‘legitimacy’ accorded the Coalition to date by the world’s highest legal body, the UN Security Council. If UN Security Council resolution 2417 (24 May 2018), condemning starvation of civilians in wartime, is to be meaningful, then it is necessary for the UNSC and its member states to halt such crimes in Yemen, to investigate them, and to call to account those responsible for perpetrating them.

I wish I could tell my friends, that people who are out there, with toasters, feel that humanitarian laws should apply to Yemen.

You don’t need to be an expert on Yemen, just have a mind, and a heart. It’s in these challenging times that we are invited to exercise what is important.

If you are interested in knowing or doing more, please get in touch with the Yemen Special Interest Group via this link. Depending on what you are like, you can also write to your MP, share the report, or even write a song.

Written by Rachel Handley, member of FPH’s Yemen Special Interest Group

The Secretary of State for Health and Social Care, Matt Hancock, has launched his prevention vision; confirming it as one of his key priorities alongside technology and workforce. PHE’s Chief Executive Duncan Selbie discusses why this is a transformative moment for public health.

Investing in public health is the smartest thing we can do – good health underpins a strong economy.

For years we have known that prevention is better than cure and that we should be moving away from a system that prioritises treatment, to one that can also predict and prevent poor health.

Up until now efforts to invest in prevention within our healthcare, workplaces and communities have fallen short. The NHS Five Year Forward View had genuine ambition to reverse this, but it failed to deliver with short term priorities taking precedence.

The Secretary of State, through publishing his prevention vision has shown he is determined to move more resources into prevention. And he has signalled the NHS Long Term Plan as one way to fund this.

We welcome this, as a promise of prioritising prevention is meaningless without investment.

Good health is of course about more than only healthcare. Wider determinants, including income, remain the most important thing.

But we all have a part to play and there are actions the NHS can take, as part of its Long Term Plan, which will help everyone to live for longer in better health.

Using bedside moments to promote wellbeing and avoid future illness is one step the NHS could take. For example, a smoker who comes into hospital for any reason should be helped to quit smoking. And then when they are ready to leave hospital, this support should continue in the community and at home.

The opportunity that we have now as a public health family is to embrace the energy and commitment of the Secretary of State, and to see more investment going into improving the public’s health.

A promise of radical action with no commitment, where nothing gets done is not an option. Realistic and tangible movement where we can actually achieve something is what we want to see.

This shift in focus is an exciting milestone and should signal a synchronised effort to place prevention at the heart of national and local government, and the NHS.

A sinister droning, plaintive chords and the distant tramp of marching feet.

Blood red letters emerge from the void, forming words, and then fading back into the night.

WAR ALWAYS TAKES A HEAVY TOLL…
EVEN AFTER THE FIGHTING ENDS, CONFLICTS CONTINUE TO KILL.

This is the riveting opening scene of “War & the National Immune System”, a short animated film written and produced by the Global Violence Prevention SIG in collaboration with Médecins Sans Frontières/Doctors Without Borders. You can watch it here. The film’s online release this week is the culmination of a long process to which many different people have made extremely valuable contributions. Therefore in the fine tradition of the Oscars acceptance speech, let me tell you the story of how this project came about.

As a special interest group (SIG), we have found it quite helpful to have an overarching theme or a primary project for each year (would you like to know about next year’s theme?). I like to think that this helps to guide and focus our activities. Sometime in mid-2017, we decided that our theme for 2018 would be the association between armed conflict and infectious disease, using the dual centenary of World War One’s conclusion and the Spanish Flu pandemic as a “hook”. It was an obvious opportunity to take an anniversary that we knew would be getting a lot of media attention (as it should), and to present it with a slight twist – a different perspective which would hopefully be memorable enough to help us draw attention to the wider public health impacts of armed conflict.

I had been mainly thinking in terms of some journal articles and a bit of public speaking, but when I mentioned our proposed annual theme to John Middleton he responded “Why don’t you make a film about it?”. It wasn’t an idea that I had ever considered, perhaps because of my total ignorance of film making. But what is a public health training programme for, if not for expanding your experience of different methods of communicating with the public?

Members of the SIG formed a working group and started putting together a script. The many benefits of collaboration quickly became apparent. We had a vision and the evidence base to create the film’s narrative, but no experience of script-writing to guide us. Fortunately we had colleagues from the Film SIG to advise and steer us towards the sort of concise story-telling that was required. We had vague ideas about what producing such a film might cost, but no contacts to give us actual quotes.

Luckily the Film SIG was again able to help, putting us in touch with independent film makers who gave us some estimates. We had the potential to raise some funds, but probably not enough to cover the scope of our ambitions. Fortuitously my contacts at Médecins Sans Frontières (MSF) were interested in our ideas, so much so that they were happy to collaborate with us and to bear half of the total cost. They also brought fresh eyes to our script, new perspectives and some invaluable experience in using film as a tool of public communication.

A huge amount of work by many people went into the writing process. How to adequately describe the calamity of the Spanish Flu pandemic, coming at the end of the worst war the world had ever seen, in less than 30 seconds? How best to balance the messaging priorities of MSF with those of the FPH? It took months. Having decided that animation was the best medium to communicate all of the information that we wanted to get across, we pitched the finished script to a range of studios, and chose one called Beakus on the basis of the storyboards they created in response to our brief.

While the animators got to work, sending us progressively more and more detailed storyboards and tantalizing clips of what the finished film might look like, we turned our attention to where on earth we would find our half of the money. By a happy coincidence, a generous financial bequest had recently been given to the Faculty for the explicit purpose of supporting public health film collaborations, and we were able to get approval to use some of it for this project.

In a brilliant sequel to this good news, the excellent MSF team managed to secure the services of Academy Award winning British actor Jim Broadbent, who kindly donated his time and his mellifluous tones to the voiceover. We could never have achieved these things alone.

Anyone interested in using film to better communicate public health ideas should definitely consider joining the Film SIG. Anyone interested in exploring (through a variety of mediums) the public health impacts of conflict and war should unquestionably think about joining the Global Violence Prevention SIG. If you have a passion, find a SIG. If there isn’t one yet, then start one – this is a member-driven organisation. And if you’re part of a SIG contemplating an ambitious project, consider who you might be able to partner with. Collaboration is an enriching and empowering experience.

This week, at the Faculty of Public Health in Scotland’s Annual Conference, there will be welcome debates and discussion on the related topics of the right to health and on ethics in, of, and for the public’s health. A crucial component of this will be a session on the nanny state debate, a matter on which the Faculty of Public Health (FPH) is about to publish a report.

Public health activities are sometimes characterised as standing in conflict with individual rights. The reasons for this are straightforward: we often find tensions between what might serve an individual’s interests and what might promote the public or general good. In this sense, rights are of fundamental importance: it is rights that protect a person’s dignity; that allow our lives to be our own. In philosophical jargon, our rights place side-constraints on what the government might do.

Regardless of how much general good might follow from interferences with our rights, they protect us from torture and ill treatment, and from arbitrary and unjustified interferences with our liberty. Rights underpin a system of justice that accords with the rule of law. Rights protect our privacy and our personal and family lives. They safeguard our freedoms to associate with others, to practise a religion (or not), and to express our views freely. Rights protect minority interests against ‘the tyranny of the majority’. A society that doesn’t recognise and protect rights places us within, or at risk of falling into, political angst.

However, rights are not just about protections of ‘negative freedoms’; guards against wrongful government interference. To be realised, the empowering ethos of rights requires that government take measures that help promote a healthy society. This includes things like ensuring the right to a sound education, good housing, and of course conditions in which we can enjoy good health. Rights also require that government’s guard against and keep a check on other powerful actors—for example large corporations—whose influence may be enormous, and who present considerable threats if left with unchecked power.

As such, rights—including the right to health—are essential to good and ethical public health. Yet there are real difficulties, at times, in communicating this. One of the barriers to meaningful understanding within public debates on health policy is the nanny state, which is frequently presented as a ‘knock down’ argument. Where a proposed public health intervention is ridiculed for being ‘nanny statist’, the implication is that it necessarily and illegitimately interferes with our rights: that it is meddling rather than empowering. The impact of nanny state rhetoric is enormous. And, unsurprisingly, nanny state accusations are often simplistic. Indeed, they are often arbitrary or incoherent.

We must recognise that, at its best, the nanny state refers to valid concerns. None of us wants to live in a ‘health theocracy’. Just as too much emphasis can be given to simplistic accounts of individual autonomy, so too can the value of health be overstated. We want the right balance between autonomy and health, and require to think about other things that matter too. A good society recognises and promotes a range of important values, including health, happiness, liberty, autonomy, connectedness, and community. Our enjoyment of these is related directly to good government. Often a nanny state accusation is not even formally a claim about the rights of individuals. It may be a smokescreen to cover hidden interests, or just an easily used political slur that tarnishes a policy that in reality cannot—on any count—be said to be ‘nannying’.

I authored the report at FPH’s invitation, as a member of the special interest group on ethics, in consultation with experts in public health ethics, training, practice, and leadership. It provides examples and scrutinises how nanny state claims work in practice. It aims to explain the principled positions that support nanny state accusations, and expose the ways in which claims of nanny statism may be used without principled coherence. The report also provides practical guidance on means of responding to nanny state claims within public and political debates. It is hoped that we can advance health—and other important social agendas—without reducing ourselves to unhelpful slurs and slogans that perpetuate harms and injustices. Our focus should rather be on achieving a more fair and equitable society.

Written by John Coggon Honorary Member of the Faculty of Public Health, and Professor of Law, Centre for Health, Law, and Society, University of Bristol Law School. John launched a report entitled ‘The Nanny State Debate: A Place Where Words Don’t Do Justice’, which was launched at FPH in Scotland’s Annual Conference in Peebles on 2 November 2018.

As Scotland’s Minister for Public Health and Wellbeing, I am under no illusion about the public health challenges our country faces.

One of the things that struck me when I was first appointed was the shocking variation in life expectancy across our communities, a difference sometimes measured in decades. This is simply not acceptable in a wealthy country where we have the tools to do something about it.

I am determined we tackle this and Scotland’s entrenched health inequalities. Different government departments, the wider public and third sectors all have a significant role to play. In this blog I will outline my approach and some of the action the Scottish Government, COSLA and partners across the public and third sectors are taking.

Whole system approach

Those working in areas that impact on health and wellbeing must combine their efforts and work together to address the most complex issues affecting people and communities. For example, if we want to help someone who misuses drugs to recover, we have to address factors such as employment, mental health and social isolation. If we want to tackle entrenched problems such as housing, homelessness, knife crime and addiction, this can’t be done in isolation. Complex problems require collaborative and integrated approaches.

Human rights

Fundamental to a genuinely whole systems approach is being absolutely committed to protecting, respecting and realising human rights. Scotland has a proud history of recognising and supporting the rights of people. I am determined that we build on this and put human rights approaches in all we do to strengthen public health.

Key principles

The Scottish Government and COSLA have agreed key principles to public health reform:

reducing inequalities

collaboration and engagement

prevention and early intervention

empowering communities

fairness and equality

intelligence and innovation

These are not abstract ideals, they genuinely inform and shape everything we do.

Public Health Priorities for Scotland

In June, the SG and COSLA published our Public Health Priorities. This was an important moment, and the true impact of this statement of consensus may not be appreciated for some years. The priorities are an agreement that we must focus on and embed the following in all we do:

places and communities

early years and young people

mental wellbeing

alcohol, tobacco and drugs

a sustainable and inclusive economy

healthy weight and physical activity

Legislation, strategies and action plans

We have taken action and outlined our approaches to specific areas of public health, and there is more to come. Highlights include:

Alcohol – we introduced the world-leading Minimum Unit Pricing policy and later this year we will publish a refreshed Alcohol Preventative Framework

Substance misuse – our new strategy will also be published later this year, highlighting the need for services to respect everyone’s right to health

Mental health – our Mental Health Strategy states clearly that we must treat mental health with the same commitment as physical health. We have backed this with an extra £250 million in the 2018/19 Programme for Government

Physical activity – our physical activity delivery plan, published in July, sets out how we will to help people be more active, more often, and our ambition to cut inactivity by 15% by 2030

Diet and healthy weight – our wide-ranging delivery plan, published this summer, set the goal to halve child obesity by 2030. We are consulting on plans to restrict promotion of foods such as crisps, sweets and chocolate

Scotland’s new public health body

The next key milestone in our reforms is the establishment of the new national public health body, Public Health Scotland. It will have influence across Scotland, be visible in providing expertise, support and leadership, and it must engage and be available to organisations, communities and the public.

Crucially, Public Health Scotland will be jointly accountable to both Scottish Government and Local Government, reflecting the joint, integrated approach that is key to tackling Scotland’s public health challenges.

Together, the establishment of Public Health Scotland, the Public Health Priorities for Scotland and a commitment to working in partnership underpin our ambitions for reform. Working together we will realise our ambitions and improve the health and wellbeing of our population.

Disclaimer

The aim of this blog is to encourage discussion and debate on public health issues. The views expressed here are the personal views of authors, and the content does not reflect the official position of the Faculty of Public Health. However, discussion generated here may be used to influence the development of organisational policy.